scholarly journals 135. Designing And Evaluating A Pharmacist-Driven Approach to Outpatient Azithromycin Stewardship

2020 ◽  
Vol 7 (Supplement_1) ◽  
pp. S79-S79
Author(s):  
Christina Tran ◽  
Paul Lata ◽  
Kristin Tindall ◽  
Susanne Barnett ◽  
Prakash Balasubramanian
Keyword(s):  
Antimicrobial Agents ◽  
Respiratory Infections ◽  
Negative Impact ◽  
Primary Care Providers ◽  
Outpatient Setting ◽  
Care Providers ◽  
Prescribing Practices ◽  
Copd Exacerbations ◽  
Post Hoc

Abstract Background After collecting data on diminishing S. pneumoniae susceptibility rates, the Madison VA aimed to optimize azithromycin prescribing practices by enhancing the involvement of outpatient pharmacists. This study aimed to develop effective pharmacy-led stewardship teams in the outpatient setting and assess their collective impact on promoting judicious azithromycin prescribing. Methods Madison VA outpatient pharmacists initiated an azithromycin stewardship protocol in 4/2019 to intervene on prescriptions suspected to be discordant with expert guidelines for COPD, pneumonia, sinusitis, or bronchitis. After pharmacist follow-up with providers to discuss potentially inappropriate prescriptions, recommendations and outcomes were subsequently documented in the electronic health record. Given the longitudinal nature of outpatient pharmacist interventions, a post-hoc survey was provided to assess pharmacists’ perceptions of this protocol, barriers to intervention, and areas for improvement. Results Between 10/2018 and 4/2020, 18 pharmacists intervened on 42 outpatient azithromycin prescriptions to recommend alternative antibiotics with improved streptococcal coverage or supportive care alone. Indications warranting the most intervention included COPD exacerbations, upper respiratory infections, and bronchitis. Factors most often cited by pharmacists as barriers to intervention included negative impact on workload, provider reluctance, and insufficient time for follow-up. All surveyed pharmacists believed that prescribers, most commonly primary care providers, were fairly or very receptive to their recommendations. Data evaluated from 10/2018 to 12/2019 revealed a 45% decrease in azithromycin prescribing. Conclusion Azithromycin prescribing has steadily declined at the Madison VA, reinforced by the implementation of an outpatient pharmacist stewardship team. To more seamlessly integrate recommendation-making into pharmacist workflow, determining solutions to identified barriers is currently underway. It is hoped that continued pharmacist involvement in outpatient antibiotic stewardship can be a sustainable practice and transferrable strategy to other antimicrobial agents in the future. Disclosures All Authors: No reported disclosures

Impact of a Personalized Audit and Feedback Intervention on Antibiotic Prescribing Practices for Outpatient Pediatric Community-Acquired Pneumonia

2020 ◽  
Vol 59 (11) ◽  
pp. 988-994 ◽  
Author(s):  
Maria Carmen G. Diaz ◽  
Lori K. Handy ◽  
James H. Crutchfield ◽  
Adriana Cadilla ◽  
Jobayer Hossain ◽  
...  
Keyword(s):  
Positive Impact ◽  
Intervention Group ◽  
Primary Care Providers ◽  
Outpatient Setting ◽  
Community Acquired Pneumonia ◽  
Audit And Feedback ◽  
Antibiotic Prescribing ◽  
Care Providers ◽  
Prescribing Practices ◽  
The Impact

Antibiotic choice for pediatric community-acquired pneumonia (CAP) varies widely. We aimed to determine the impact of a 6-month personalized audit and feedback program on primary care providers’ antibiotic prescribing practices for CAP. Participants in the intervention group received monthly personalized feedback. We then analyzed enrolled providers’ CAP antibiotic prescribing practices. Participants diagnosed 316 distinct cases of CAP (214 control, 102 intervention); among these 316 participants, 301 received antibiotics (207 control, 94 intervention). In patients ≥5 years, the intervention group had fewer non–guideline-concordant antibiotics prescribed (22/103 [21.4%] control; 3/51 [5.9%] intervention, P < .05) and received more of the guideline-concordant antibiotics (amoxicillin and azithromycin). Personalized, scheduled audit and feedback in the outpatient setting was feasible and had a positive impact on clinician’s selection of guideline-recommended antibiotics. Audit and feedback should be combined with other antimicrobial stewardship interventions to improve guideline adherence in the management of outpatient CAP.

scholarly journals 145. Monthly Antibiotic Prescribing Peer Comparison Combined with In-person Education Decreases Antibiotic Prescribing for Acute Respiratory Infections

2020 ◽  
Vol 7 (Supplement_1) ◽  
pp. S83-S83
Author(s):  
Shelby J Kolo ◽  
David J Taber ◽  
Ronald G Washburn ◽  
Katherine A Pleasants
Keyword(s):  
Primary Care ◽  
Respiratory Infections ◽  
Primary Care Providers ◽  
The United States ◽  
Delivery Mode ◽  
Antibiotic Prescribing ◽  
Acute Respiratory Infections ◽  
Care Providers ◽  
Intervention Period ◽  
Provider Education

Abstract Background Inappropriate antibiotic prescribing is an important modifiable risk factor for antibiotic resistance. Approximately half of all antibiotics prescribed for acute respiratory infections (ARIs) in the United States may be inappropriate or unnecessary. The purpose of this quality improvement (QI) project was to evaluate the effect of three consecutive interventions on improving antibiotic prescribing for ARIs (i.e., pharyngitis, rhinosinusitis, bronchitis, common cold). Methods This was a pre-post analysis of an antimicrobial stewardship QI initiative to improve antibiotic prescribing for ARIs in six Veterans Affairs (VA) primary care clinics. Three distinct intervention phases occurred. Educational interventions included training on appropriate antibiotic prescribing for ARIs. During the first intervention period (8/2017-1/2019), education was presented virtually to primary care providers on a single occasion. In the second intervention period (2/2019-10/2019), in-person education with peer comparison was presented on a single occasion. In the third intervention period (11/2019-4/2020), education and prescribing feedback with peer comparison was presented once in-person followed by monthly emails of prescribing feedback with peer comparison. January 2016-July 2017 was used as a pre-intervention baseline period. The primary outcome was the antibiotic prescribing rate for all classifications of ARIs. Secondary outcomes included adherence to antibiotic prescribing guidance for pharyngitis and rhinosinusitis. Descriptive statistics and interrupted time series segmented regression were used to analyze the outcomes. Results Monthly antibiotic prescribing peer comparison emails in combination with in-person education was associated with a statistically significant 12.5% reduction in the rate of antibiotic prescribing for ARIs (p=0.0019). When provider education alone was used, the reduction in antibiotic prescribing was nonsignificant. Conclusion Education alone does not significantly reduce antibiotic prescribing for ARIs, regardless of the delivery mode. In contrast, education followed by monthly prescribing feedback with peer comparison was associated with a statistically significant reduction in ARI antibiotic prescribing rates. Disclosures All Authors: No reported disclosures

scholarly journals Evaluation of a multidisciplinary lipid clinic to improve the care of individuals with severe lipid conditions: a RE-AIM framework analysis

2021 ◽  
Vol 2 (1) ◽  
Author(s):  
Laney K. Jones ◽  
Megan McMinn ◽  
David Kann ◽  
Michael Lesko ◽  
Amy C. Sturm ◽  
...  
Keyword(s):  
Primary Care ◽  
Program Effectiveness ◽  
Primary Care Providers ◽  
Care Providers ◽  
Lipid Levels ◽  
Framework Analysis ◽  
Lipid Clinic ◽  
Adherence Counseling ◽  
Clinically Significant

Abstract Background Individuals with complex dyslipidemia, or those with medication intolerance, are often difficult to manage in primary care. They require the additional attention, expertise, and adherence counseling that occurs in multidisciplinary lipid clinics (MDLCs). We conducted a program evaluation of the first year of a newly implemented MDLC utilizing the RE-AIM (reach, effectiveness, adoption, implementation, and maintenance) framework to provide empirical data not only on program effectiveness, but also on components important to local sustainability and future generalizability. Methods The purpose of the MDLC is to increase the uptake of guideline-based care for lipid conditions. Established in 2019, the MDLC provides care via a centralized clinic location within the healthcare system. Primary care providers and cardiologists were invited to refer individuals with lipid conditions. Using a pre/post-study design, we evaluated the implementation outcomes from the MDLC using the RE-AIM framework. Results In 2019, 420 referrals were made to the MDLC (reach). Referrals were made by 19% (148) of the 796 active cardiology and primary care providers, with an average of 35 patient referrals per month in 2019 (SD 12) (adoption). The MDLC saw 83 patients in 2019 (reach). Additionally, 50% (41/82) had at least one follow-up MDLC visit, and 12% (10/82) had two or more follow-up visits in 2019 (implementation). In patients seen by the MDLC, we found an improved diagnosis of specific lipid conditions (FH (familial hypercholesterolemia), hypertriglyceridemia, and dyslipidemia), increased prescribing of evidence-based therapies, high rates of medication prior authorization approvals, and significant reductions in lipid levels by lipid condition subgroup (effectiveness). Over time, the operations team decided to transition from in-person follow-up to telehealth appointments to increase capacity and sustain the clinic (maintenance). Conclusions Despite limited reach and adoption of the MDLC, we found a large intervention effect that included improved diagnosis, increased prescribing of guideline-recommended treatments, and clinically significant reduction of lipid levels. Attention to factors including solutions to decrease the large burden of unseen referrals, discussion of the appropriate number and duration of visits, and sustainability of the clinic model could aid in enhancing the success of the MDLC and improving outcomes for more patients throughout the system.

Documenting Patients’ and Providers’ Preferences When Proposing a Randomized Controlled Trial: A Qualitative Exploration

2021 ◽  
Author(s):  
Devesh Oberoi ◽  
Cynthia Kwok ◽  
Yong Li ◽  
Cindy Railton ◽  
Susan Horsman ◽  
...  
Keyword(s):  
Randomized Controlled Trial ◽  
Study Design ◽  
Controlled Trial ◽  
Primary Care Providers ◽  
Referral Letter ◽  
Care Providers ◽  
Randomized Controlled ◽  
Number Of Patients ◽  
Follow Up Care

Abstract Background With advances in cancer diagnosis and treatment, women with early-stage breast cancer (ESBC) are living longer, increasing the number of patients receiving post-treatment follow-up care. Best-practice survivorship models recommend transitioning ESBC patients from oncology-provider (OP) care to community-based care. While developing materials for a randomized controlled trial (RCT) to test the feasibility of a nurse-led Telephone Survivorship Clinic (TSC) for a smooth transition of ESBC survivors to follow-up care, we sought to explore patients’ and OPs’ reactions to our proposed recruitment methods. Methods We used a qualitative study design with content analysis, and a two-pronged approach. We interviewed OPs, seeking feedback on ways to recruit their ESBC patients for the trial, and ESBC patients, seeking input on a questionnaire package assessing outcomes and processes in the trial. Results OPs identified facilitators and barriers and offered suggestions for study design and recruitment process improvement. Facilitators included the novelty and utility of the study and simplicity of methods; barriers included lack of coordination between treating and discharging clinicians, time constraints, language barriers, motivation, and using a paper-based referral letter. OPs suggested using a combination of electronic and paper referral letters and supporting clinicians to help with recruitment. Patient advisors reported satisfaction with the content and length of the assessment package. However, they questioned the relevance of some questions (childhood trauma) while adding questions about trust in physicians and proximity to primary-care providers. Conclusion OPs and patient advisors rated our methods for the proposed trial highly for their simplicity and relevance then suggested changes. These findings document processes that could be effective for cancer-patient recruitment in survivorship clinical trials.

Comparisons of Patient and Physician Expectations for Cancer Survivorship Care

2009 ◽  
Vol 27 (15) ◽  
pp. 2489-2495 ◽  
Author(s):  
Winson Y. Cheung ◽  
Bridget A. Neville ◽  
Danielle B. Cameron ◽  
E. Francis Cook ◽  
Craig C. Earle
Keyword(s):  
Cancer Survivorship ◽  
Primary Care Providers ◽  
Preventive Health ◽  
Primary Cancer ◽  
Survivorship Care ◽  
Care Providers ◽  
Agreement Rate ◽  
Cancer Management ◽  
Survivorship Care Planning

Purpose To compare expectations for cancer survivorship care between patients and their physicians and between primary care providers (PCPs) and oncologists. Methods Survivors and their physicians were surveyed to evaluate for expectations regarding physician participation in primary cancer follow-up, screening for other cancers, general preventive health, and management of comorbidities. Results Of 992 eligible survivors and 607 physicians surveyed, 535 (54%) and 378 (62%) were assessable, respectively. Among physician respondents, 255 (67%) were PCPs and 123 (33%) were oncologists. Comparing patients with their oncologists, expectations were highly discrepant for screening for cancers other than the index one (agreement rate, 29%), with patients anticipating significantly more oncologist involvement. Between patients and their PCPs, expectations were most incongruent for primary cancer follow-up (agreement rate, 35%), with PCPs indicating they should contribute a much greater part to this aspect of care. Expectations between patients and their PCPs were generally more concordant than between patients and their oncologists. PCPs and oncologists showed high discordances in perceptions of their own roles for primary cancer follow-up, cancer screening, and general preventive health (agreement rates of 3%, 44%, and 51%, respectively). In the case of primary cancer follow-up, both PCPs and oncologists indicated they should carry substantial responsibility for this task. Conclusion Patients and physicians have discordant expectations with respect to the roles of PCPs and oncologists in cancer survivorship care. Uncertainties around physician roles and responsibilities can lead to deficiencies in care, supporting the need to make survivorship care planning a standard component in cancer management.

Abstract 184: Patterns of Outpatient Follow-up after Acute Myocardial Infarction: Follow-up Frequency is Associated with Utilization of Evidence-based Therapies

2013 ◽  
Vol 6 (suppl_1) ◽  
Author(s):  
Rebecca Vigen ◽  
Yan Li ◽  
Thomas M Maddox ◽  
Stacie Daugherty ◽  
Steven M Bradley ◽  
...  
Keyword(s):  
Myocardial Infarction ◽  
Acute Myocardial Infarction ◽  
Primary Outcome ◽  
Beta Blockers ◽  
Primary Care Providers ◽  
Risk Scores ◽  
Evidence Based ◽  
Care Providers ◽  
Multivariable Analyses

Background: ACC/AHA guidelines recommend that patients with acute myocardial infarction (AMI) follow-up within several weeks of hospital discharge. Recommendations regarding intensity of following-up in the year following AMI are not provided. The relationship between frequency of follow-up and use of evidence-based therapies following AMI is unknown. Methods: 6,838 patients from 2 multicenter prospective AMI registries, PREMIER and TRIUMPH registries were studied. We divided the number of patient self-reported outpatient follow-up visits with cardiologists, primary care providers, or both into tertiles: low, medium, and high. The primary outcome was use of statins, beta blockers, aspirin, ACE/ARBs, and a composite of all four medications at 12 months among eligible patients. The association between tertiles of visits following AMI among patients who had at least one visit and primary outcome was evaluated using hierarchical multivariable modified Poisson models. Results: Mean number of follow-up visits in the year following AMI was 6 (IQR 3 - 8) and 189 (4%) of patients had no visits. In lowest tertile, patients had 1 to < 4 visits, in the medium tertile, 4 to < 7 visits, and in highest tertile, 7 to 59 visits. Patients in medium and high intensity tertiles were older, more likely to have insurance, and had higher GRACE 6-month mortality risk scores compared to the lowest tertile. In multivariable analyses, patients in the medium tertile were more likely to use statins and ASA than those in the lowest tertile (Figure). There were no differences in use of individual medications when comparing the highest and medium tertiles although individuals in the highest tertile were less likely to use all four medications. Conclusions: Significant variability exists in follow-up frequency following AMI and 4% of the cohort had no follow-up. Patients who had medium intensity visits were more likely to use some evidence-based medications than those with low intensity. Higher intensity visits was not associated with greater medication use. It is possible that the observed differences may be attributed to unmeasured differences among patients rather than the actual follow-up visits. Prospective studies are needed to assess key elements of outpatient visits that may lead to better utilization of evidence-based therapies.

Culturally Relevant Online Cancer Education Supports Tribal Primary Care Providers to Reduce Their Cancer Risk and Share Information About Cancer

2021 ◽  
pp. 152483992110278
Author(s):  
Katie Cueva ◽  
Melany Cueva ◽  
Laura Revels ◽  
Michelle Hensel ◽  
Mark Dignan
Keyword(s):  
Primary Care ◽  
Cancer Risk ◽  
Culturally Relevant ◽  
Cancer Education ◽  
Primary Care Providers ◽  
Future Research ◽  
Cancer Information ◽  
Care Providers ◽  
Share Information

Background Culturally relevant education is an opportunity to reduce health disparities, and online learning is an emerging avenue for health promotion. In 2014–2019, a team based at the Alaska Native Tribal Health Consortium developed, implemented, and evaluated culturally relevant online cancer education modules with, and for, Alaska’s tribal primary care providers. The project was guided by Indigenous Ways of Knowing and the principles of community-based participatory action research and was evaluated in alignment with empowerment theory. About 265 unique learners completed 1,898 end-of-module evaluation surveys between March 2015 and August 2019, and 13 people completed a follow-up survey up to 28 months post module completion. Key Findings Learners described the modules as culturally respectful and informative and reported feeling more knowledgeable and comfortable talking about cancer as a result of the modules. About 98% of the learners planned to reduce their cancer risk because of the modules, and all follow-up survey respondents had reduced their risk, including by quitting smoking, getting screened for cancer, eating healthier, and exercising more. About 98% of the learners planned to share information with their patients, families, friends, and community members because of the modules, with all follow-up survey respondents indicating that they had shared information about cancer from the modules. Implications for Practice and Further Research Culturally relevant online modules have the capacity for positive behavioral change and relatively high correlations between intent and behavior change. Future research could determine which aspects of the modules catalyzed reduced cancer risk and increased dissemination of cancer information.

scholarly journals 1475. Understanding Prescribing Practices for Uncomplicated Urinary Tract Infections (UTIs) in the Primary Care Setting: A Pilot Study

2019 ◽  
Vol 6 (Supplement_2) ◽  
pp. S538-S538
Author(s):  
Mark Pinkerton ◽  
Jahnavi Bongu ◽  
Aimee James ◽  
Michael Durkin
Keyword(s):  
Primary Care ◽  
Urinary Tract ◽  
Urinary Tract Infections ◽  
Clinical Decision ◽  
Primary Care Providers ◽  
Care Providers ◽  
Prescribing Practices ◽  
Support Tools ◽  
Tract Infections ◽  
Clinical Decision Support Tools

Abstract Background Uncomplicated urinary tract infections (UTIs) should be treated empirically with a short course of narrow-spectrum antibiotics. However, many clinicians order unnecessary tests and treat with long courses of antibiotics. The objective of this study was to understand how internists clinically approach UTIs. Methods We conducted semi-structured qualitative interviews of community primary care providers (n = 15) and internal medicine residents (n = 15) in St. Louis, Missouri from 2018 to 2019 to explore why clinical practices deviate from evidence-based guidelines. Interviews were transcribed, de-identified, and coded by two independent researchers using NVivo qualitative software. A Likert scale was used to evaluate preferences for possible interventions. Results Several common themes emerged. Both providers and residents ordered urine tests to “confirm” presence of urinary tract infections. Antibiotic prescriptions were often based on historical practice and anecdotal experience. Providers were more comfortable treating over the phone than residents and tended to prescribe longer courses of antibiotics. Both providers and residents voiced frustrations with guidelines being difficult to easily incorporate due to length and extraneous information. Preferences for receiving and incorporating guidelines into practice varied. Both groups felt benchmarking would improve prescribing practices, but had reservations about implementation. Pragmatic clinical decision support tools were favored by providers, with residents preferring order sets and attendings preferring nurse triage algorithms. Conclusion Misconceptions regarding urinary tract infection management were common among residents and community primary care providers. Multifaceted interventions that include provider education, synthesis of guidelines, and pragmatic clinical decision support tools are needed to improve antibiotic prescribing and diagnostic testing; optimal interventions to improve UTI management may vary based on provider training level. Disclosures All authors: No reported disclosures.

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